Return to work after cancer: a key health outcome

IN Australia, the incidence of cancer diagnoses is increasing owing to improved patient awareness, screening programs and better diagnostics – in 2018, 138 321 new cases were diagnosed, an approximate threefold increase from incidence rates in 1982. The past decade has ushered dramatic improvements in personalised, biological and technical expertise in cancer therapy that has resulted in significant declines in cancer mortality rates. Due to a rising cancer incidence and a reduced mortality, the number of Australians surviving cancer has grown substantially.

Cancer diagnoses in working-age people are becoming more common, with almost half of adult cancer survivors aged less than 65 years (here and here). Despite progress in treatment, cancer survivors must live with the adverse effects of treatment over the medium to long term. These effects, whether physical or emotional, can negatively affect all aspects of their lives, including their capacity to maintain a professional activity. Statistics from the United Kingdom indicate that one in four people face poor health or disability after treatment for cancer, one in six patients living with and beyond cancer care experience chronic fatigue, one in eight live with mental health problems, and one in ten people live with moderate to severe pain. Cancer has a negative impact on employment patterns, with studies estimating that between 10% and 38% of patients do not return to work after a successful treatment for cancer (here, here and here).

While many cancer survivors do well in general terms, a significant proportion continue to experience medical or psychological problems. For working-age survivors, the effects of cancer or its treatments may cause impairments that can lead to a prolonged absence from work, diminished prospects of obtaining or retaining employment, or ultimately, early retirement. Overall, cancer survivors are 1.4 times more likely to be unemployed than healthy controls, although with differing rates depending on the diagnosis. At 1–2 years after cancer treatment, approximately 40% of survivors fail to return to work (here, here and here), with numerous others underemployed or with significant limitations on their work during that intervening period. While some of these survivors will have a decreased ability to work, many are both willing and able to return to work following treatment and without residual disabilities.

For cancer survivors, employment positively affects their quality of life, self-esteem and personal finances. In addition, employment provides a distraction from the focus on their illness, as well as providing a sense of normalcy, purpose and identity. Conversely, unemployment and long term absenteeism from work are harmful to mental health and physical recovery. Not being able to work is also a loss for the employer and society at large from reduced productivity.

Why don’t cancer survivors return to work when they would be expected to? Vocational rehabilitation is defined as “whatever helps someone with a health problem to stay at, return to and remain in work”. While this may sound vague and difficult to implement, it tells a fundamental truth: every case is different and must be managed accordingly. But in its simplicity there are also answers: the barriers to return to work may be to do with the individual, health care professionals, or employers. Successful return to work is about identifying and removing barriers.

A key reason why health care professionals, particularly doctors, neglect return to work is traditional training in the (bio)medical model. At its heart, the medical model is reductionist – clinical practice is aimed at identification and treatment of pathology, recovery is absence of pathology. In the past, with significantly higher mortality rates in cancer, this model has dominated. As survival has improved, this view has persisted, but the reasons for work disability can only be understood and managed by the biopsychosocial model – the reasons people don’t return to work are far less likely to be physical (“bio”) and far more likely to be psychological or social (including the work context).

By way of illustration, a brief clinical vignette illustrates two barriers not related to the individual. One of the authors (DB, an occupational physician) was asked to assess and advise on prognosis for return to work for a 30-year-old woman who had been absent from work for 12 months with a diagnosis of Hodgkin’s lymphoma. After the assessment, he spoke to the oncologist, who said: “I had no idea she wasn’t back at work – she’s been in remission for 6 months”. He hadn’t asked her about work because he didn’t see it as a clinical outcome. The employer was reluctant to refer for assessment because of the emotive response many people have to a cancer diagnosis.

Only relatively recently has the training of doctors included the biopsychosocial model. Far more training in this is provided to allied health professionals. To remove individual patient barriers involves the skill sets of all members of the clinical team, and tailored multidisciplinary rehabilitation including, when necessary, physiotherapy, occupational therapy and psychology.

Improving return to work outcomes in cancer patients

Since many working-age cancer survivors are both willing and able to return to work, it is important that health care providers properly assess and assist patients in accessing programs that support their return to work process. A Cochrane Review of randomised controlled trials has shown that multidisciplinary interventions (including career counselling, patient education and counselling, biofeedback-assisted behavioural training and/or physical exercise) improve the rate of cancer survivors returning to work. But when performed in isolation, these interventions have shown no improvement to care as usual, which demonstrates the many facets of returning to work.

Coordination between clinicians, other health care providers and, most importantly, patients is essential for delivering a multidisciplinary intervention. However, this can be challenging to implement and difficult for patients to follow through with. For example, the most convenient setting for multidisciplinary teams is in the hospital setting, but this is far less convenient for many patients who are no longer receiving active curative treatment and are ready to engage in return-to-work programs.

Outside of hospital settings, training to use existing and validated tools for assessing work capacities are not readily available to community health care providers involved in the return to work process. Novel models, including the CancerAid Coach Program, which delivers evidence-based interventions digitally and remotely, may address some of these challenges.

An emerging but increasingly common barrier for getting cancer survivors to return to work is that clinicians, especially at a tertiary level, have little information, directive or incentivisation to make decisions about sustainable return to work. In a study by Leenson and colleagues, the combination of occupational counselling and physical exercise promoted significantly higher return to work rates for a group of cancer survivors (86% at 2 years) over unmatched historical estimates (66% at 18 months). The concluding remarks from this group, and in keeping with the available Cochrane Review, strongly suggest a multidisciplinary approach, ideally involving an occupational physician, with education and exercise as key determinants in promoting the improved return to work outcomes for patients after a cancer diagnosis.

What is the way forward?

We need a specific driver for clinicians — return to work should be a key health outcome measure from every clinical intervention. Not just in a cancer diagnosis, but especially so, because of the increasingly good clinical outcomes that are not being matched by return to work (and full engagement in life) outcomes. The Royal Australasian College of Physicians’ Consensus statement on the health benefits of good work is a catalyst for this goal, since many peak health care bodies (particularly the medical Colleges) are signatories to the principles, including that:

“The provision of good work is a key determinant of the health and wellbeing of employees, their families and broader society.”

A collaborative approach can improve clinician training, and education can demystify this area with simple first steps, including asking the question “what is your job?” and introducing the expectation of successful outcomes including return to work early. Understanding that remission does not necessarily equal return to function, and the role of biopsychosocial barriers, enables the skill sets of all members of the multidisciplinary team to be recognised and valued.

Authors bios to come:

Dr Raghav Murali-Ganesh is the co-Founder and President of CancerAid, the number one cancer app in Australia, the US and the UK. It has won the Emerging Company of the year 2017 (AusBiotech/Johnson and Johnson), Best Global Startup (Sir Richard Branson), Best Startup creating social impact (Steve Wozniak) and the EY Accelerating Entrepreneur award. Dr Murali-Ganesh is a radiation oncologist.

Jonny Lo is a medical doctor who completed his PhD in medical technology and basic science with the University of Melbourne. He has worked closely with several innovative health-tech start-ups and is currently Program Manager of ANDHealth, Australia’s only dedicated program to support the commercialisation of clinically validated digital health technologies in Australia.

Dr Zachary Tan is a medical doctor and Chief Strategy Officer at CancerAid, a leading Australian health technology start-up. He is passionate about the intersection of clinical medicine, digital health and health policy in improving healthcare outcomes for patients on a broad scale.

Kieran Ballurkar is a postgraduate medical student at the University of Sydney and a graduate in applied and pure mathematics, currently working as a data analyst at CancerAid. He is interested in applying analytic techniques to healthcare data to discover insights and new ways of promoting health.

Daniel Tian is a combined degree science and medicine student, majoring in computer science at the University of Sydney.

Simonie Fox is the Group Strategy Manager – Rehabilitation/Claims at AIA Australia. She started her career as a registered nurse and has over 20 years’ experience in occupational rehabilitation with a special interest in oncology. She is passionate about achieving better health outcomes for income protection claimants who have cancer and to support them to return to wellness and work. 

Dr David Beaumont is an occupational physician and director of Fit For Work Ltd in New Zealand. He is a past president of the Australasian Faculty of Occupational and Environmental Medicine and lead for the Faculty team which developed the Consensus Statement on the Health Benefits of Good Work.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.